At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first?
Constipation
Indigestion
Swollen ankles
Urinary frequency
None
None
The Correct Answer is B
A. Constipation: While constipation can be uncomfortable, it is not typically considered an immediate threat to a patient's health in a cardiac unit setting. It requires assessment and intervention but is not the highest priority.
B. Indigestion can be a subtle symptom of myocardial infarction (MI) or acute coronary syndrome (ACS), particularly in older adults, women, or clients with diabetes. Clients experiencing "indigestion" may be describing chest discomfort, which requires immediate assessment to rule out a cardiac event. Early identification and intervention for cardiac symptoms are critical to prevent further complications.
C. Swollen ankles can indicate fluid retention, which is a common sign of heart failure. While this symptom requires attention, it does not typically indicate an immediate life-threatening issue compared to potential cardiac ischemia associated with "indigestion."
D. Urinary frequency: This could be related to medications or other conditions. While it should be addressed, it is not the most critical issue compared to potential acute cardiac symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Detaching the needle from the syringe before discarding it increases the risk of needlestick injuries and is not recommended.
B. Placing broken glass in a wastebasket increases the risk of injury to housekeeping staff; it should be disposed of in a puncture-proof container.
C. Recapping needles increases the risk of needlestick injuries and is not recommended unless there are no alternatives available.
D. Placing lancets in a puncture-proof container is the correct procedure for preventing puncture injuries, as it safely contains sharp objects and reduces the risk of accidental needlesticks.
Correct Answer is B
Explanation
A. Beef liver - Beef liver is high in cholesterol and should be limited in the diet of someone with increased cholesterol levels.
B. Egg whites - Egg whites are low in cholesterol and can be a good source of protein for someone with increased cholesterol levels. It's the yolk of the egg that contains most of the cholesterol, so recommending egg whites is a good choice.
C. Steamed clams - Clams are low in cholesterol, but they are high in sodium, which may not be recommended for someone with increased cholesterol levels, depending on their overall dietary needs.
D. Broiled lobster - Lobster is high in cholesterol and should be limited in the diet of someone with increased cholesterol levels.
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